Mental Health Sequelae of Extreme Violence Case 1: A Woman Who Could Not Remember Her Name
Introduction
During the unfolding events of the terrorist attack on the World Trade Center twin towers on
September 11, 2001, a middle-aged Caucasian woman enters the Emergency Room of a
hospital located a few blocks from the World Trade Center. She is asking frantically whether
or not her son has been brought to the hospital’s ER with injuries. She has not been able to
reach him on his cellular phone – a situation that has never occurred before. He had a job
on the 11th floor of one of the towers.
The emergency room nurse calls you in to meet with her.
The nurse has obtained: BP 140/100; HR 124 because the woman appears to be so upset
about her son being missing that she is unable to remember her own name. When she is
asked to give details about herself and her son, she can only repeat her son’s name and
birth date over and over again.
She has not accepted the idea of being a patient in the ER; there are no medical records on
her son because he has never been admitted to this hospital, either today or on any
previous occasion.
Question 1 out of 5
You are sitting with the woman alone in a small consulting room at the ER. Which of the
following is NOT an appropriate first step in the medical examination of this patient?
a. Introduce yourself and then immediately conduct a physical examination
The answer is correct.
You would not conduct a physical examination because this woman has not accepted
that she is a patient needing treatment for herself. During and immediately after a
terrorist attack or event(s) of extreme violence, individuals will seek non-medical
assistance as well as medical assistance from their doctors and neighborhood health
center and hospital.
b. Introduce yourself and try to see if you can begin a conversation
The authors disagree; trying to begin a conversation is an appropriate first step.
This individual is in a terrible social crisis. She is afraid and terrified that her son has
been killed in the World Trade Center attack. This fact is confirmed when she begins to
speak to you.
c. Acknowledge her fears and ask how you can be helpful
The authors disagree. Acknowledging her fears and asking how you can be
helpful are appropriate first steps.
Frequently, health professionals, including mental health practitioners, are afraid to
open up "Pandora’s Box" by asking the patient or client about their traumatic life
experiences. They may not know what to do once the traumatized individual shares their
tragedy, and they are afraid that the patient will lose control and not be able to be
treated in the brief time the doctor has with the patient.
d. Consider ruling out delirium
The authors disagree; ruling out delirium is an appropriate first step.
The essential feature of delirium is disturbances of consciousness. That is, reduced
clarity of awareness of the environment, with reduced ability to focus, sustain, or shift
attention. A change in cognition, such as memory deficit, disorientation, or language
disturbance, also occurs that is not due to a pre-existing or evolving dementia. Delirium
occurs over a short period of time, usually hours to days.
You proceed to evaluate the patient for delirium and you find that she is articulate and
reveals no signs of chaotic or disorganized thinking, or that she is responding to internal
auditory hallucinations. Thus, this woman has no signs of delirium.
e. Consider that the patient may have an acute stress disorder
The authors disagree; considering acute stress disorder is an appropriate first step.
This patient is a very likely candidate for an acute stress disorder since she is
experiencing an acute state of emotional distress related to a serious traumatic life
situation. That is, the possible murder of her son by the terrorist attacks on the World
Trade Center.
The major clinical features of acute stress disorder are:
Dissociative symptoms (e.g., numbness, detachment; reduction in awareness of
surroundings; inability to recall an important aspect of the trauma)
Recurrent memory phenomena
Avoidance of thoughts, places, and people that remind him of the trauma
Marked symptoms of anxiety and arousal (e.g., poor sleeping, irritability, poor
concentration, hypervigilance, exaggerated startle response, motor restlessness)
Significant distress leading to impairment in social and/or occupational activities
Initial Examination
The doctor has:
Introduced himself/herself
Established that the patient is not delirious, psychotic, or uncontrollably agitated
Acknowledged the patient’s traumatic situation
During the initial examination, the doctor has established a conversation with the patient.
There are no overt signs of psychosis or delirium. The fact that the woman cannot
remember her name or any identifying information about herself is probably due to an
emerging acute stress reaction.
Question 2 out of 5 The woman has become able to speak to the doctor and acknowledges between tears that
she is "out of her mind" with fear and worry that her son has been killed.
Which of the following are the most appropriate response at this time? (Hint: There are 3
correct answers, all must be selected)
a. Treat her condition by giving her reassurance that everything is okay and that she will
eventually find her son.
The authors disagree.
Individuals experiencing extreme violence are not looking for reassurances based upon
inadequate information. Help must be realistic and consist of concrete actions.
b. Treat her anxiety by offering her a prescription for a benzodiazepine.
The authors disagree.
A benzodiazepine cannot substitute for a relationship with a doctor that is based upon
offering concrete assistance. While these drugs might be initially helpful in reducing the
patient’s distress, they also can become habituating. At this juncture in the examination,
the doctor also knows very little about the prior medical and psychiatric history of this
patient.
c. Offer her a list of places and persons in the emergency relief effort, such as the
American Red Cross, that could assist her in finding her son.
The answer is correct.
One of the most important interventions is finding the missing, injured, or killed family
member. In international situations, this process is called family reunification. Although
the results of the search may reveal to the patient that her son has been killed, "not
knowing" the son’s whereabouts is an extremely painful situation.
In addition, the disappearance of a loved one during states of extreme violence is
probably one of the most difficult situations to cope with, along with the murder of a
child and sexual violence.
d. Inquire into her safety and security.
The answer is correct.
It is critical to immediately help establish the safety and security of the patient from
ongoing violence. For example, in this case, who is going to aid the woman during the
search for her son? Where does she live? How is she going to return safely home from
New York? Does she have any money for transportation or food?
e. Inquire into the status of other family members, and especially children, who might be
dependent upon her and her son.
The answer is correct.
In her distress she may not be able to think rationally about protection and support of
her son’s family, if he has one or the other individuals living in her household. Has she
left any children unattended at home? Is her spouse or relatives looking for her?
Similarly, does her son live with her? The doctor can help to secure for the patient, the
family situation by being in touch with family members and getting unattended children
assistance, if necessary.
Question 3 out of 5 The woman is beginning to exhibit some signs of emotional relief hearing your concrete
suggestions about where she can get assistance. She gets up and is now ready to leave.
Which of the following are appropriate next steps? (Hint: There are 2 correct answers, all
must be selected)
a. Refer her to psychiatry
The authors disagree.
This woman has a primary goal she must achieve – finding her son. Psychiatry will not
be able to assist her in this effort. At this time she does not consider herself a psychiatric
patient because her level of upset is consistent with the situation.
b. Worry that she will develop posttraumatic stress disorder or depression
The authors disagree.
The majority of individuals with a partial or full acute stress disorder do not develop
serious psychiatric illnesses such as major depression and/or PTSD.
c. Once she has found her son, offer to link her up with a "debriefing" program
The authors disagree.
While many programs and practitioners have emerged during national and man-made
disasters offering critical incident debriefing, that is, brief sessions where traumatic
events and associated emotions are relived in exquisite detail, there is no evidence that
"debriefing" prevents serious mental illness like PTSD. In fact, scientific evidence is
emerging that "debriefing" may encourage the development of PTSD.
d. Offer to assist her in finding a clergy member for assistance and support.
The answer is correct.
A major national survey by Schuster et al. (New England Journal of Medicine, 2001),
examining the support people utilized immediately after the September 11, 2001 terrorist
crisis, revealed that 98% had sought support from family members and friends and 90%
from the clergy. In issues dealing with the emotional and social consequences of extreme
violence, clergy can be especially therapeutic in helping individuals deal with the
murder of loved ones.
e. Get her name and telephone number and schedule her for an appointment to see you in
your outpatient clinic in a few days.
The answer is correct.
You have initiated the first step in establishing a therapeutic relationship with the
patient. The doctor and nurse, along with family members, friends, and the clergy, are
essential to the short- and long-term support of traumatized persons.
Question 4 out of 5 What are your greatest concerns regarding the long-term health risks for this patient? (Hint:
There are 3 correct answers, all must be selected)
a. Psychosis
The authors disagree.
It has not been demonstrated that traumatized persons develop psychotic illness, no
matter how long or severe the trauma.
b. PTSD
The answer is correct.
While the risk factors for PTSD are not fully established, the overall resiliency of this
woman to cope with her situations has not been determined. Few individuals with acute
stress disorder develop PTSD.
c. Acute and complicated grief reaction
The answer is correct.
It is almost 100% certain that this patient will develop an acute grief reaction if the son
is not found alive and safe. While this woman’s reactions are normal responses to a
terrible situation, the sudden and violent nature of her tragedy may make her
bereavement difficult and complicated, potentially developing into a major depression.
You do not have enough information at this time in regard to the son’s situation or the
patient’s social and medical background to know how events will unfold.
d. Suicidal behavior
The authors disagree.
You have no evidence that the patient will engage in suicidal behavior if she finds out
her son has been killed.
In the acute phase of a personal crisis, suicide risk is actually relatively low, as the
individual attempts to maximize their resources to solve the crisis. However, if, over
time, suicidal ideation or suicidal risk emerges, you will have established a relationship
in which the patient will be able to confide in and discuss this with you.
e. High-risk health behaviors such as cigarette smoking, drug and alcohol abuse, excessive
use of prescription medication, and unsafe sex.
The answer is correct.
During periods of extreme violence, all high-risk health behaviors are potentially
increased. You have little if any information on this patient in regard to her past and
current history on each of these behaviors.
Question 5 out of 5 The woman is very grateful for your assistance and agrees to see you again in three days.
At the time of her appointment she does not show up.
Which of the following are appropriate responses? (Hint: There are 2 correct answers, all
must be selected)
a. Do nothing
The authors disagree.
You have no idea why the patient has not kept her appointment. You can only assume
that this is not a good sign as to the status of her son and her ongoing crisis.
b. Call her immediately and have a telephone discussion with her
The answer is correct.
You have already begun to establish some trust with the patient during the emergency
room consultation. A phone call from you will help solidify in the patient’s mind your
concern for her welfare. This is a critical gesture since she might be so distraught with
grief that she withdrawn into herself and has become isolative.
c. Be concerned that the assistance this patient needs is beyond your capacity as a primary
care practitioner.
The authors disagree.
The immediate presentation of a patient experiencing extreme violence with a possible
acute stress reaction does not predict the intensity of future health care needs.
d. Try to have the patient come in for one more visit in order to make a referral to
psychiatry.
The authors disagree.
This patient will most likely not develop a psychotic disorder and will appreciate and
utilize the time and attention you have to offer her. If a serious mental illness develops
beyond your capacity to treat, you can then make a referral to psychiatry.
e. Be worried that this is a very disturbing case that will generate in you considerable
upset.
The answer is correct.
What is unique in a terrorist attack or any situation of extreme violence is that the health
care practitioner is as vulnerable as the patient to the effects of mass violence. There is
probably no other situation in medicine where doctor/nurse and patient are facing the
same danger and health risks. In fact, in some situations, medical personnel are at
greater physical and emotional risks from extreme violence than patients. In recent
conflicts, medical personnel, hospitals, and clinics have been the targets of violent
attacks. Weapons of mass destruction also pose special health risks and dangers to
medical practitioners.
Medical practitioners and their institutions must be prepared to cope with the
psychological disturbances they will experience in caring for patients exposed to mass
violence.
Summary
Acute stress and grief reactions are non-pathological states that are frequently seen in the
ER, the health center, and the primary care practitioner’s office following a terrorist attack
or other acts of extreme violence. Most individuals suffering these reactions will not develop
serious psychiatric illness.
Immediately ask about the patient’s trauma story
Establish rapport with the patient by offering him or her concrete practical
assistance, including:
--Reunification with loved ones
--Protection and safety of family members
--Basic humanitarian aid; that is, shelter and food, if needed
Recognize that all current health, mental health, and social problems will worsen
Provide basic emotional and medical support
Follow patient’s acute symptomatology over time. Eighty percent (80%) of cases will
not go on to develop serious diagnosable mental illness
Be able to recognize acute posttraumatic stress and major depression, if it develops
Limit medication in the acute phase to relief of symptoms such as insomnia and
anxiety, only if absolutely necessary to facilitate patient functioning
See patient often in brief visits to provide emotional support and actively encourage
the patient’s own coping skills and efforts
Avoid debriefing or any intrusive forced recounting by the patient of their traumatic life
experiences
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Washington, DC: Author, 1994.
2. Harvard Program in Refugee Trauma (HPRT): Terrorism Recovery Overview.
3. Mollica RF. "Traumatic outcomes: the mental health and psychosocial effects of mass
violence." In: Leaning J, Briggs SM, Chen L, eds. Humanitarian emergencies: the
medical and public health response. Cambridge, Mass: Harvard University Press; 1999.
4. Raphael B, Wilson J, eds. Psychological debriefing: Theory, practice and
evidence. Cambridge, UK: Cambridge University Press, 2000.
5. Spiegel D, Classen C. "Acute stress disorder." In Synopsis of treatments of psychiatric
disorders. 2nd ed. Gabbard G, Atkinson S, eds. Washington, DC: American Psychiatric
Press, Inc., 1996; 655-66.
Mental Health Sequelae of Extreme Violence
Case 2:
A Cambodian Woman Remembers Pol Pot
INTRODUCTION
The patient is a 35 year-old Cambodian woman complaining of headaches,
dizziness, and weakness. She has had these symptoms before, but they have
intensified since the attack of the World Trade Center four weeks ago.
PATIENT HISTORY
Current History
She has a persistent headache with dull frontal and occipital pain, without aura,
nausea, vomiting, or photophobia.
She feels weaker than usual and can hardly care for her three small children. When she wakes up in the morning and gets out of bed, she feels lightheaded and
dizzy and sometimes has to grasp a table or chair or she will fall down.
Past History
The patient was born and raised in a small rice-farming village in Cambodia. She was a
teenager when the Khmer Rouge forced her and her family into a work camp. She lived in
this camp from 1975-1979 before escaping to Thailand in 1979. In 1981 she was resettled
in America by the American government.
She was very healthy until five years ago, when her primary care physician diagnosed her
as having Type II Diabetes. Her diabetes has been well controlled with diet and metformin
500 mg bid.
PHYSICAL EXAM
Vitals: BP 140/90; P 80; BMI 25
General: The patient is a middle-aged Cambodian woman who looks much older
than her stated age. Although she is alert, she looks tired and distressed.
There are no signs of inappropriate behavior.
HEENT: Fundoscopic exam without retinal hemorrhages or papilledema
Neck: Supple; no bruits; no thyroid abnormality
Chest: Lungs clear to auscultation bilaterally Cardiovascular: Normal heart sounds, no murmur
Abdomen: Soft, non-distended, non-tender
Extremities: Pedal pulses 2+, no edema
Neurologic: No signs of cognitive or speech impairment (through Cambodian
interpreter); CN II- XII intact; no focal weakness or sensory deficits;
reflexes 2+ throughout.
Other: Skin: Faint bruises in long thin streaks all over her body
Breasts: No masses or abnormalities
LABORATORY RESULTS
CBC, electrolytes, BUN/Cr, liver function tests, urinalysis, TSH are normal.
HbA1c: 8.0 Random glucose 160
QUESTION 1 OUT OF 5
Which of the following statements are most likely correct regarding the diagnosis and
management of this patient? (Hint: There are 2 correct answers, all must be selected)
a. Symptoms are related to diabetes.
b. Symptoms are related to migraine.
c. Symptoms are related to her diabetic medication
d. Symptoms might be related to the bruises all over the patient’s body
e. Symptoms are related to the terrorist attack on the World Trade Center
CORRECT! Please read below for feedback for all answer choices
and to compare your answers with your peers.
Correct Choices:
d. Symptoms might be related to the bruises all over the patient’s body
The answer is correct.
In the presence of unexplained bruising, there should be a high index
of suspicion for domestic violence. Physical abuse could also account
for the nonspecific symptoms of headache, weakness, and dizziness.
e. Symptoms are related to the terrorist attack on the World Trade Center
The answer is correct.
At this point in your examination of the patient, you have no clear
evidence that these are stress-related symptoms due to the patient’s
reactions to the terrorist attacks. You are aware, however, that the
current terrorist attacks can re-exacerbate her distress from the
Khmer Rouge Period (1975-1979), and that in many cultures,
emotional distress is primarily expressed through somatic complaints.
Incorrect Choices:
a. Symptoms are related to diabetes.
The authors disagree.
Her diabetic control has worsened slightly, but the degree of
hyperglycemia is not likely to account for her symptoms.
b. Symptoms are related to migraine.
The authors disagree.
Her current headache pattern is more suggestive of tension-type
headache. She has had similar headaches in the past.
c. Symptoms are related to her diabetic medication
The authors disagree.
She has previously taken metformin without side effects. Questioning
about her dietary intake reveals no changes that might indicate
hypoglycemic episodes.
QUESTION 2 OUT OF 5
Through further questioning of the patient, it does not appear to you likely that her
headaches, dizziness, and weakness are due to migraines. While you proceed with the
evaluation, you also focus on managing the patient’s diabetes. You advise her to use
acetaminophen 650 mg every 4 to 6 hours as needed to relieve her headache symptoms.
Since the history reveals no changes in activity or diet that might explain her worsening
diabetic control, you increase the metformin to 850 mg bid and ask the patient to return in
two weeks.
Upon return, the patient’s initial complaints have all increased. Her headaches have
continued unabated, and the weakness and dizziness are so severe that she spends most of
her time in bed. Upon physical examination, this time you notice not only the "streaky"
bruising but also many small red circles on her chest and breasts. The blood pressure is
128/88 and there are no other changes on physical exam
The medications you have given the patient have not improved her headache
symptoms or the control of her diabetes. Which of the following are correct
regarding the continued management of this patient? (Hint: There are 3 correct
answers, all must be selected)
a. You focus on diabetes control by asking the patient to bring
records from home glucose monitoring to the next visit.
b. You consider placing the patient on a new oral diabetic agent.
c. Headache symptoms may be due to a neurological problem so
you order an MRI.
d. Headaches, dizziness, and weakness may be due to somatic
expression of severe stress.
e. You ask the patient whether anyone is hitting her at home and
whether she feels safe at home.
CORRECT! Please read below for feedback for all answer choices
and to compare your answers with your peers.
Correct Choices:
a. You focus on diabetes control by asking the patient to bring records from
home glucose monitoring to the next visit.
The answer is correct.
It is appropriate to obtain home glucose readings in order to better
assess diabetic control.
d. Headaches, dizziness, and weakness may be due to somatic expression
of severe stress.
The answer is correct.
e. You ask the patient whether anyone is hitting her at home and whether
she feels safe at home.
The answer is correct.
It is important to sensitively but directly question the patient about
any history of physical abuse. The patient reports that her home
situation is stable and she is not experiencing abuse.
Incorrect Choices:
b. You consider placing the patient on a new oral diabetic agent.
The authors disagree.
It is too early to know whether the increased dose of metformin will be
sufficient for improving glycemic control. A better understanding of
factors leading to worsening control is needed to guide further
treatment.
c. Headache symptoms may be due to a neurological problem so you order
an MRI.
The authors disagree.
Since her headaches have been present in the past, and there are no
abnormalities on neurological exam, it is reasonable to defer
neuroimaging at this time.
QUESTION 3 OUT OF 5
You pause to reflect on this case. It appears that the patient’s symptoms and
poor diabetes control are related to the September 11th attack on the World
Trade Center. You proceed to ask the patient the question: "Many of my
patients have felt that September 11th had a big effect on their health and
well-being. Has this been the case for you?"
The patient responds to this question by crying.
Which of the following is NOT an appropriate way to proceed with your medical
interview?
a. Asking for more information on how the recent terror attacks
have affected her health.
b. Asking her for more information about recent and past
traumatic life situations.
c. You are not sure whether to obtain a full trauma history during
this interview or to work with the information already obtained.
You tell the patient that you appreciate hearing her history and
would like to ask more during her next visit.
d. Acknowledging the patient’s use of common traditional healing
techniques called "coining" and "cupping" and advising against
these techniques.
e. You ask the patient what diagnosis she would be given for her
symptoms in Cambodia.
CORRECT!
Please read below for feedback for all answer choices
and to compare your answers with your peers.
Correct Choices:
d. Acknowledging the patient’s use of common traditional healing
techniques called "coining" and "cupping" and advising against these
techniques.
The answer is correct.
Considerable evidence exists as to the positive value of traditional
healing techniques. Many herbalist and alternative medical approaches
may produce dangerous outcomes, especially if practiced by
"charlatan" healers. However, in this specific case, there is no evidence
that cupping and coining are harmful to the patient.
"Coining" is a traditional healing technique practiced by Southeast
Asians to treat pain, colds, exhaustion, vomiting, and headaches. The
procedure consists of a menthol oil or ointment applied to the area
requiring treatment. The edge of a coin is then rubbed over the area
with a downward stroke. It is believed that the coining exudes the "bad
wind" from the body. Often, superficial, reddish-purple, non-painful
bruises resembling "strap marks" will appear after a coining.
"Cupping" is another technique used by Southeast Asians to relieve
pain. This procedure consists of an alcohol-soaked cotton or piece of
paper, which is inserted into a special cup and ignited, and the cup is
then applied to the skin. Suction is created and the cup remains in
place for 15-20 minutes. The suction is believed to exude the pain.
Cupping can result in 2-inch circular reddish-purple burn/bruise marks
that are painful to the touch.
Coining and cupping are Cambodian techniques administered by
friends or family members and appear to be effective against
emotional distress in the short term without negative side effects,
except for mild bruising of the skin.
Incorrect Choices:
a. Asking for more information on how the recent terror attacks have
affected her health.
The authors disagree. This is an appropriate step.
The patient reveals to you that since 9/11 she has become increasingly
frightened that she will be the target of the next terrorist attack. So,
she has actually barricaded herself and her children in her room every
night. She feels that she is reliving the Pol Pot genocide all over again.
b. Asking her for more information about recent and past traumatic life
situations.
The authors disagree. This is an appropriate step.
Current health responses to any form of mass violence or extreme life
experiences build upon prior traumatic experiences. This patient was
severely traumatized under the Pol Pot regime as a young woman
between 1975-1979. Eighteen months ago she also experienced a
break-in by Cambodian gang members. She and her children were
robbed at gunpoint, though no one was physically injured.
c. You are not sure whether to obtain a full trauma history during this
interview or to work with the information already obtained.
You tell the patient that you appreciate hearing her history and would
like to ask more during her next visit.
The authors disagree. This is an appropriate step.
You have a small amount of time with the patient; you do not want to
generate too much emotion. It is best to acknowledge the importance
of the traumatic life history and collect additional details during each
upcoming medical visit. Over time you’ll know the patient’s entire
trauma history.
e. You ask the patient what diagnosis she would be given for her symptoms
in Cambodia.
The authors disagree. This is an appropriate step.
Most health problems have associated community or folk diagnoses
and sometimes overlap with Western medical and psychiatric
diagnoses. Sometimes they do not. Obtaining folk diagnoses will not
only help you identify any major differences in medical approaches
between yourself and the patient, but they will also reveal the amount
of community stigma associated with the illness.
QUESTION 4 OUT OF 5
Now that you understand that the patient has had a major somatic and psychosocial
response to 9/11, you revisit her treatment plan. The patient has also revealed through
the interpreter that she believes she has "Pruoy Cet," which in Cambodia describes a folk
diagnosis in which the patient has a "deep sadness seen on the patient’s face."
You decide to determine if the patient has major depression and/or posttraumatic stress
disorder (PTSD), two psychiatric diagnoses common in survivors of extreme violence.
Which of the following is NOT an appropriate next step?
a. Conduct a simple mental status exam.
b. Review with the patient all of the major symptoms that comprise the
DSM-IV diagnosis of major depression.
c. You review with the patient all of the major symptoms of PTSD
d. You will consider whether the diagnoses of major depression and PTSD
have any cultural equivalency in Cambodian culture.
e. You will share your psychiatric diagnoses with the patient using both
Western and folk diagnoses.
Correct Choices:
a. Conduct a simple mental status exam.
The answer is correct. This is not an appropriate step.
A simple mental status examination is usually insufficient to make the
diagnosis of major depression and/or PTSD in highly traumatized
persons.
A semi-structured interview is best with the patient providing simple
yes/no or quantitative responses due to the high emotions that
sometimes arise producing poor responses to open-ended questions.
Incorrect Choices:
b. Review with the patient all of the major symptoms that comprise the
DSM-IV diagnosis of major depression.
The authors disagree. This is an appropriate step.
To make the DSM-IV diagnosis of major depression, five or more of the
following symptoms have to be present during the same two-week
period, and represent a change from previous functioning [at least one
of the symptoms must be either (1) depressed mood or (2) loss of
interest or pleasure]:
(1) Depressed mood
(2) Markedly diminished interest or pleasure
(3) Weight loss
(4) Insomnia or hypersomnia
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy
(7) Feelings of worthlessness or excessive guilt
(8) Poor concentration
(9) Suicidal ideation
These symptoms do not count for major depression if they are due to a
medical diagnosis, drug addiction, bipolar disorder, or acute grief
reaction.
c. You review with the patient all of the major symptoms of PTSD
The authors disagree. This is an appropriate step.
Again, there are no short cuts since all of the symptoms have major
treatment implications.
The DSM-IV diagnosis of PTSD can only be made if the patient first
meets criterion A: The patient has been exposed to a life-threatening
event that involves intense fear, helplessness, or horror.
The remaining major symptom criteria for PTSD include:
Criterion B [one or more symptoms]: Recurrent memory phenomena.
That is, recurrent memories of the event, including flashbacks, daytime
memories, and nightmares, and psychological distress upon being
exposed to reminders of the event.
Criterion C [three or more symptoms]: Avoidant phenomena and/or
psychic numbing. That is, avoidance of thoughts, feeling, and places
and restriction in affect, emotions, and interest in activities,
respectively.
Criterion D [two or more symptoms]: Persistent symptoms of
increased arousal (not present before the trauma), such as irritability,
poor sleep, increase autonomic functioning, poor concentration,
hypervigilance, and exaggerated startle response.
Duration of the symptoms must be more than one (1) month.
d. You will consider whether the diagnoses of major depression and PTSD
have any cultural equivalency in Cambodian culture.
The authors disagree. This is an appropriate step.
In fact, the symptom phenomenology of Pruoy Cet is very close to the
DSM-IV diagnosis of major depression. In contrast, the word for PTSD
in Cambodian is “Tierur-na-kam.” It is a new folk diagnosis in
Cambodia based upon the DSM-IV. Cambodian culture has no folk
diagnosis equivalent to PTSD.
e. You will share your psychiatric diagnoses with the patient using both
Western and folk diagnoses.
The authors disagree. This is an appropriate step.
The patient will appreciate that you understand her folk diagnoses and
that you explain the differences to her between your approach to
diagnosis and treatment as compared to similarities and differences in
her cultural orientation.
QUESTION 5 OUT OF 5
You have come to the conclusion that the patient has major depression and PTSD.
Which of the following is NOT an appropriate therapeutic approach?
a. Administer an antidepressant
b. Closely follow the management of the patient’s diabetes
c. Offer brief counseling
d. Family meeting with children
e. Immediately refer to psychiatry or the clinic’s behavioral health unit.
CORRECT! Please read below for feedback for all answer choices
and to compare your answers with your peers.
Correct Choices:
e. Immediately refer to psychiatry or the clinic’s behavioral health unit.
The answer is correct. This is not an appropriate step.
Most traumatized persons prefer to be treated by their PCP; they
should only be referred to psychiatry if they have a serious mental
illness (e.g., bipolar disorder) or are actively suicidal. If referred to
psychiatry, it should be done in a sensitive way so the patient does not
feel abandoned.
Incorrect Choices:
a. Administer an antidepressant
The authors disagree. This is an appropriate therapeutic approach.
A properly selected antidepressant will help treat both the major
symptoms of PTSD and depression.
b. Closely follow the management of the patient’s diabetes
The authors disagree. This is an appropriate therapeutic approach.
Poor management of the patient’s diabetes will exacerbate her
psychiatric distress and vice versa. Treatment of the patient’s diabetes
will improve with the successful treatment of the patient’s psychiatric
disorders.
c. Offer brief counseling
The authors disagree. This is an appropriate therapeutic approach.
In caring for highly traumatized patients in primary care, the most
effective form of counseling includes brief supportive interventions that
primarily focus on:
1) the patient’s coping skills, and
2) clear communication that reinforces a strong, positive doctor-
patient relationship.
Brief counseling of traumatized patients is an ongoing process of "a
little, a lot, over a long period of time." This model fits nicely into PCPs’
limited time with each patient and is very well received by traumatized
patients, as they perceive a continuous, ongoing interest in their
traumatic life history. Furthermore, in this case, the PCP should
reassure the patient about the unrealistic possibility that she and her
family will be attacked by terrorists.
d. Family meeting with children
The authors disagree. This is an appropriate therapeutic approach.
Clearly, the children are also being seriously affected by the patient’s
short and long-term distress. The children themselves may be in need
of counseling or additional social services.
SUMMARY
Violence builds upon violence. That is, a current experience of extreme violence will
reactivate in patients previous mental health responses to violence. This patient had been
previously traumatized on two separate occasions, including the Pol Pot genocide (1975-
1979) and gang break-in in America. In cases affected by extreme violence, it is important
to:
Be aware of the patient’s traumatic life history. Every PCP should have an overall
understanding of any trauma that could have occurred in the lives of their patients,
whether they are refugees or immigrants or American-born. For example, any
Cambodian person 25 years or older (born before 1979) has most likely lived in a
concentration camp. This type of awareness of a patient’s history is crucial to
understanding his/her current health status.
Be prepared to recognize that a current terrorist attack or situation of mass violence
can:
Re-exacerbate previous mental health responses
Destabilize the treatment of all major illnesses such as diabetes, hypertension, and
heart disease
Result in impaired social and economic functioning
Many cultures express emotional distress through somatic complaints and associated
folk diagnoses.
Patients will meet the DSM-IV diagnostic criteria for PTSD and major depression
although these diagnoses are not known cross-culturally.
Culturally diverse patients will use traditional healing techniques (e.g., coining) and
Western medical care (e.g., psychotropic medication) simultaneously without
conflict. The treatment of medical and mental health disorders must be approached together
to maximize outcomes.
REFERENCES
1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Washington, DC: Author, 1994.
2. Harvard Program in Refugee Trauma (HPRT): Human Spirit – Why Stories?
3. Mollica RF, Tor S, Lavelle J. Pathways to Healing: A Viewmaster Guide to Khmer Mental Health, 1998. Available in English and Cambodian. Http://www.hprt-cambridge.org
4. Cassano P, Fava M. Depression and public health: an overview. Journal of Psychosomatic
Research. 53 (2002); 849-57.
5. Yeatman GW, Dang VV. Cao gio (coin rubbing). Journal of the American Medical Association. 244 (1980): 2748-9
6. Kinzie, J. D., Riley, C., McFarland, B., Hayes, M., Boehnlein, J., Leung, P., et al.
(2008). High prevalence rates of diabetes and hypertension among refugee psychiatric patients. J Nerv Ment Dis, 196(2), 108-112.
7. Trento M, Passera P, Borgo E, Tomalino M, Majardi M, Cavallo F, Porta M. A 5-year
randomized controlled study of learning, problem solving ability, and quality of life
modifications in people with Type 2 diabetes managed by group care. Diabetes Care. March 2004;27(3):670-675.
Mental Health Sequelae of Extreme Violence
Case 3: A Reporter Who Cannot Sleep
Introduction
45 year-old single male comes to see you for a routine yearly physical examination.
He has been your patient for over ten years. He is a distinguished journalist for a
major national newspaper. In fact, he is a well-known news reporter, having just
returned from reporting on the conflict in Afghanistan.
The patient’s only complaint is a problem with insomnia since returning to America
four weeks ago. He tells you that he is feeling fatigued because he isn’t sleeping
well.
You perform a complete physical examination, which is normal. You know this
patient well; he has no previous history of medical, psychiatric, or surgical
treatments.
QUESTION 1 OUT OF 10
Which of the following statements is NOT correct regarding the diagnosis of
insomnia in this patient?
a. You should ask the patient whether he has had trouble
sleeping in the past
b. You should ask the patient about the pattern of sleep
disturbance
c. You should ask him about what he has already tried, if
anything, to help with sleep
d. You should assume that his sleep disturbance is caused by jet
lag
e. You should ask about his activity and diet
Correct Choices:
d. You should assume that his sleep disturbance is caused by jet lag
The answer is correct.
The timing of this patient’s sleep disturbance is not consistent with
circadian disturbance as the sole cause for his current sleep
disturbance, one month after return from Afghanistan. While jet lag
undoubtedly contributed to sleep disturbance in the first week after his
return, his circadian rhythm should have adjusted after a week or so.
Other factors that may be contributing to current sleep disturbance
should be sought.
Incorrect Choices:
a. You should ask the patient whether he has had trouble sleeping in the
past
The authors disagree. This statement is correct.
The clinical approach varies for acute vs. chronic insomnia. The patient
tells you that he hasn’t had problems with insomnia in the past.
b. You should ask the patient about the pattern of sleep disturbance
The authors disagree. This statement is correct.
It is important to determine the pattern of sleep disruption: trouble
falling asleep (long sleep latency); trouble staying asleep (excessive or
prolonged awakenings); or feeling unrefreshed after sleep. The patient
reports trouble falling asleep and frequent brief awakenings. He does
not feel restored after a night’s sleep.
c. You should ask him about what he has already tried, if anything, to help
with sleep
The authors disagree. This statement is correct.
Most patients try a variety of measures to help with sleep before
consulting a physician. The patient tells you he initially took some
lorazepam that he had on hand for jet lag in the past but ran out a
couple of weeks ago.
e. You should ask about his activity and diet
The authors disagree. This statement is correct.
The timing and nature of activity and dietary intake have major
impacts on sleep and should always be determined in evaluating any
sleep disorder. This patient tells you that he had trouble sleeping
immediately when he returned from Afghanistan, so he started staying
up late to watch late-night comedy shows after getting home from
work around 9 pm. He usually eats a large meal, often with a glass of
wine, around 10 pm. He drinks coffee while working during the
afternoon. He also has an erratic bedtime, retiring anywhere between
10 p.m. and 3 a.m.
QUESTION 2 OUT OF 10
Based on the previous information, you decide that the patient has acute onset
insomnia related to initial circadian rhythm disruption, with continuing
conditioned insomnia related to poor sleep hygiene.
Which of the following statements are correct regarding the management of
insomnia in this patient? (Hint: There are 2 correct answers, all must be
selected)
a. You should advise an over-the-counter sleep aid such as
diphenhydramine
b. You should review sleep hygiene principles with the patient
c. You should renew his prescription for lorazepam and advise
him about short-term intermittent use for insomnia
d. You should recommend further evaluation by a sleep specialist
e. You should give the patient a prescription for zaleplon
Correct Choices:
b. You should review sleep hygiene principles with the patient
The answer is correct.
Based on the history you have obtained, poor sleep hygiene is likely to
be playing a role in this patient’s insomnia.
c. You should renew his prescription for lorazepam and advise him about
short-term intermittent use for insomnia
The answer is correct.
This patient has successfully used lorazepam in the past for treatment
of circadian disturbance. Although improvement in sleep hygiene may
be of most value, judicious use of lorazepam over the course of a few
weeks may be helpful in reducing sleep latency.
You advise the patient to limit use to 2 or 3 times weekly to avoid
dependence. An alternative medication with demonstrated
effectiveness for short-term insomnia and limited potential for
dependence would be zolpidem.
Incorrect Choices:
a. You should advise an over-the-counter sleep aid such as
diphenhydramine
The authors disagree.
Although over-the counter antihistamines are widely used, their
efficacy for treatment of insomnia has not been established.
Diphenhydramine has a relatively long half-life and is often associated
with morning sedation.
d. You should recommend further evaluation by a sleep specialist
The authors disagree.
The primary care clinician can initiate evaluation and management of
many sleep disorders, including this one, in the primary care setting.
e. You should give the patient a prescription for zaleplon
The authors disagree.
Zaleplon is an ultra short-acting agent that acts as an agonist at the
benzodiazepine receptor component of the gamma-aminobutyric
receptor complex. It is useful primarily for patients who report
prolonged nighttime awakenings.
SLEEP HYGIENE PRACTICES
Sleep hygiene practices that should be changed in this patient include:
Avoiding alcohol close to bedtime. The patient should have no alcohol within 5 hours
of bedtime. Alcohol is a poor hypnotic agent and can increase nighttime awakenings.
Avoiding caffeine after lunch, including coffee, tea, soda, and chocolate. Caffeine can
cause shallow sleep and nighttime awakenings.
Avoiding a heavy meal at bedtime. Going to bed on an empty stomach should also
be avoided. A light snack may be beneficial.
Adhering to a regular sleep schedule. Bedtime and wake time should be consistent
for 7 days a week, even after a bad night.
Other important sleep hygiene practices include:
Sleeping only as much as needed to feel rested. The patient should stay in bed for
roughly the number of hours of sleep he is achieving per night, rather than staying in
bed trying to get a few extra minutes of sleep.
Limiting stimulating or anxiety-producing activities during the two hours before bed.
Activities such as work, housework, or working on the computer should also be
avoided during a nighttime awakening.
Getting regular exercise. Over time, regular exercise has a positive effect on sleep
quality.
Avoiding use of the bed for anything other than sleep or sexual activity. During an
awakening that lasts more than 20 minutes or so, the patient should get out of bed
and do something relaxing and distracting, such as reading.
Adjusting the environment in the bedroom to reduce noise and light.
QUESTION 3 OUT OF 10
Two months have passed since the patient first came to you with complaints of
insomnia. The insomnia, in fact, has worsened. The patient admits that he is
consuming increasing amounts of alcohol to help him fall asleep – but it is no
longer working. You are wondering if the patient is dealing with an upsetting
situation he has not shared with you.
Which of the following statements are true? (Hint: There are 2 correct answers,
all must be selected)
a. When patients have had an experience of extreme violence,
they can become self-medicating with alcohol and other
substances of abuse to treat their insomnia.
b. Patients who have experienced extreme violence can have bad
dreams but usually do not have nightmares of the traumatic
events.
c. You should directly ask the journalist if he had a terrible
experience in Afghanistan.
Correct Choices:
a. When patients have had an experience of extreme violence, they can
become self-medicating with alcohol and other substances of abuse to
treat their insomnia.
The answer is correct.
When consumed at bedtime, alcohol has an initial stimulating effect
upon non-alcoholics, followed by a decrease in time to fall asleep.
However, with continued and increased consumption until bedtime,
alcohol’s disruptive effects on sleep increase and its sleep-promoting
effects decrease (Vitello, 1997).
c. You should directly ask the journalist if he had a terrible experience in
Afghanistan.
The answer is correct.
Proceed to the next slide to see the patient's answer.
He shares with you his recent experience. While driving outside of
Kabul, he and his friend, a photojournalist, were trapped in a barrage
of rocket fire. He stepped out of the car to see what was going on. A
rocket was fired into the car injuring his colleague as he watched from
a hillside. He tried to approach the car but was turned back by more
rocket fire. He could not get to aid his friend for over two hours. By
then, the photojournalist had bled to death. He tells you how guilty he
feels.
Incorrect Choices:
b. Patients who have experienced extreme violence can have bad dreams
but usually do not have nightmares of the traumatic events.
The authors disagree.
Nightmares are common; the nightmare often reveals the tragic
events that have occurred. The PCP can usually have the patient reveal
their trauma story by discussing the content of their nightmares.
CASE PROGRESSION
You directly ask the journalist if he had a terrible experience in Afghanistan, and he
shares with you his recent experience. While driving outside of Kabul, he and his
friend, a photojournalist, were trapped in a barrage of rocket fire. He stepped out of
the car to see what was going on. A rocket was fired into the car injuring his
colleague as he watched from a hillside. He tried to approach the car but was
turned back by more rocket fire. He could not get to aid his friend for over two
hours. By then, the photojournalist had bled to death. He tells you how guilty he
feels.
He also tells you that he has been having almost nightly nightmares of a terrorist
attack blowing up a car that he is driving with his photojournalist colleague sitting
beside him.
QUESTION 4 OUT OF 10
Upon hearing this story, you should diagnose the patient with PTSD.
a. True
b. False
Correct Choices:
b. False
The answer is correct.
The patient may fulfill the criteria for a DSM-IV diagnosis of PTSD.
However, it must first be considered that the patient has an acute grief
reaction due to the tragic loss of his friend. The patient’s initial
presentation of insomnia is consistent with this diagnosis. This patient
also presented with some symptoms characteristic of a major
depressive episode, such as feelings of sadness associated with poor
sleep, poor appetite, and weight loss.
Incorrect Choices:
a. True
The authors disagree.
SCREENING
You are concerned that the patient is developing a major psychiatric disorder. You
are on the alert for this possibility during the patient’s next visit four (4) weeks later. On your advice, he has stopped drinking, but the medication you have given
him to help his sleep is not working. He is feeling more despondent and guilty about his friend’s death. You decide to administer to him a screening instrument for PTSD
called the Harvard Trauma Questionnaire (HTQ) and a screening instrument for major depression called the Hopkins Symptom Checklist-25 (HSCL-25).
The scales reveal the following symptoms:
Table 01: Hopkins Symptom Checklist-25 (HSCL-25) - Depression Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Low energy . . X .
Self-blame . . . X
Crying X . . .
Lowered libido . X . .
Poor appetite . . X .
Difficulty sleeping . . . X
Hopelessness . X . .
Sadness . . . X
Loneliness X . . .
Suicidal ideation X . . .
Feeling trapped . X . .
Worrying . . X .
No interest . . X .
Everything an effort . . X .
Worthlessness . . X .
TOTAL SCORE = 39/15 = 2.60
(Depression score is determined by adding individual scores [1-4] for each item and dividing by 15;
patient is "checklist positive" for major depression if score is >1.75)
Table 02: Harvard Trauma Questionnaire (HTQ) - PTSD Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Recurrent memories . . X .
Reexperiencing the event . . X .
Nightmares . . . X
Detachment X . . .
Unemotional X . . .
Startled X . . .
Poor concentration . . X .
Trouble sleeping . . . X
Guardedness X . . .
Irritability . X . .
Avoiding activities reminiscent of trauma X . . .
Inability to remember trauma .X . . .
Less interest in daily activities .X .X . .
Feeling there is no future X .X . .
Avoiding traumatic thoughts X .. .. ..
Sudden emotional or physical reaction
when reminded of trauma . X . .
TOTAL = 31/16 = 1.94
(PTSD score is determined by adding individual scores [1-4] for each item and dividing by 16; patient
is "checklist positive" for PTSD if score is >2.00)
QUESTION 5 OUT OF 10
Which of the following statements is true?
a. Based upon the two screening instruments, this patient is
checklist positive for major depression and PTSD.
b. The patient’s major PTSD symptoms are avoidance symptoms.
c. The patient has serious daily nightmares that disrupt his sleep.
This PTSD symptom will be relatively easy to treat with
medication.
d. The patient diagnosed with major depression and partial
symptoms of PTSD should be initially prescribed an
antidepressant. One good choice for major depression with
PTSD symptoms and/or PTSD is sertraline (Zoloft) or
paroxetine (Paxil).
Correct Choices:
d. The patient diagnosed with major depression and partial symptoms of
PTSD should be initially prescribed an antidepressant. One good choice
for major depression with PTSD symptoms and/or PTSD is sertraline
(Zoloft) or paroxetine (Paxil).
The answer is correct.
These selective serotonin reuptake inhibitors (SSRIs) are excellent first
choices because they are generally well tolerated and have a fairly
quick onset of action.
Choices among SSRIs for major depression alone are fluoxetine
(Prozac) and escitalopram (Lexapro).
Incorrect Choices:
a. Based upon the two screening instruments, this patient is checklist
positive for major depression and PTSD.
The authors disagree.
The patient meets the threshold for major depression but not for
PTSD.
b. The patient’s major PTSD symptoms are avoidance symptoms.
The authors disagree.
While the patient does not meet all DSM-IV criteria for PTSD, this
patient reveals serious PTSD symptoms of recurrent memory
phenomena. That is, he is constantly playing over in his mind
memories of the death of his friend and colleague.
c. The patient has serious daily nightmares that disrupt his sleep. This
PTSD symptom will be relatively easy to treat with medication.
The authors disagree.
Nightmares are extremely difficult to treat with medication as already
demonstrated by the failure of standard use of benzodiazepines to
treat his insomnia.
QUESTION 6 OUT OF 10
The patient should be told of the most common side effects of the SSRIs.
Which of the following are NOT common side effects of the SSRIs? (Hint: there
are 2 correct answers, all must be selected)
a. Gastrointestinal problems such as nausea, vomiting, and
diarrhea
b. Dizziness and drowsiness
c. Headaches
d. Dry mouth, weight gain, and vivid dreams
e. Sexual problems, including decreased libido, anorgasmia,
impotence, and delayed ejaculation
f. Serotonin syndrome
g. Fatality with overdose
Correct Choices:
f. Serotonin syndrome
The answer is correct.
Although it may emerge in rare cases, serotonin syndrome is not
considered a common side effect of SSRIs.
g. Fatality with overdose
The answer is correct.
SSRIs do not cause fatalities upon overdose in suicidal patients.
Incorrect Choices:
a. Gastrointestinal problems such as nausea, vomiting, and diarrhea
The authors disagree.
b. Dizziness and drowsiness
The authors disagree.
c. Headaches
The authors disagree.
d. Dry mouth, weight gain, and vivid dreams
The authors disagree.
e. Sexual problems, including decreased libido, anorgasmia, impotence,
and delayed ejaculation
The authors disagree.
QUESTION 7 OUT OF 10
In your pharmacological management of this patient you will:
a. "Start Low, Go Slow"
b. Increase the dose of the SSRI in four week intervals
c. Treat the patient's depression with medication for six months once
remission occurs
Correct Choices:
a. "Start Low, Go Slow"
The answer is correct.
With any age it is recommended to maximize patient’s compliant use
of the antidepressant medication to start with as low doses as possible
and then increase the dosage slowly. This minimizes side effects and
maximizes your potential for achieving a therapeutic dose level.
Incorrect Choices:
b. Increase the dose of the SSRI in four week intervals
The authors disagree.
SSRIs should be increased in 1-2 week intervals. Most SSRIs take 2-3
weeks for initial symptom reduction and require 4-6 weeks to reach full
effectiveness once they reach therapeutic dose range.
c. Treat the patient's depression with medication for six months once
remission occurs
The authors disagree.
It is recommended that the patient’s symptoms be in remission for one
year before discontinuation of treatment.
QUESTION 8 OUT OF 10
This patient’s nightmares have not responded well to the initial SSRI.
You should add low dose trazodone to treat this symptom.
a. True
b. False
Correct Choices:
a. True
The answer is correct.
Nightmares in individuals who have experienced extreme violence are
often poorly responsive to antidepressants. The biology of this
phenomenon is not known. Empirically, low dose trazodone has been
effective in treating nightmares.
Incorrect Choices:
b. False
The authors disagree.
QUESTION 9 OUT OF 10
After twelve weeks, you repeated the HSCL-25 and the HTQ. If symptom scores on the
HSCL-25 were over 1.75, you would not be too concerned since you would not expect
remission at this time.
a. True
b. False
Correct Choices:
b. False
The answer is correct.
After twelve (12) weeks, the symptom score on the HSCL-25 should be
under 1.75, indicating successful treatment of the patient’s depression.
However, some patients may show improvement in symptom severity
while scoring greater than 1.75 on the HSCL-25. In these cases of
partial remission, the PCP should continue the medication by raising
the dose, if necessary, as well as reviewing other possible contributing
factors, including poor compliance and life events. Some patients who
are severely psychologically damaged from trauma may have chronic
depressions that are difficult to treat, requiring extra attention in
getting proper levels of counseling and social support.
Partial remission of depression is a predictor of chronicity and re-
exacerbation of depressive illness.
Reduction in PTSD symptoms is usually tied to reduction in depressive
symptoms.
Incorrect Choices:
a. True
The authors disagree.
QUESTION 10 OUT OF 10
After successful treatment, you and the patient decide to discontinue medication.
Which of the following statements is true?
a. You can taper off the medication over a two-week period.
b. After eight weeks off medication the patient should be reevaluated for
reoccurrence of symptoms.
Correct Choices:
b. After eight weeks off medication the patient should be reevaluated for
reoccurrence of symptoms.
The answer is correct.
The patient should be seen again in eight weeks after medication has
been discontinued to monitor for relapse.
Incorrect Choices:
a. You can taper off the medication over a two-week period.
The authors disagree.
Once the decision is made with the patient to discontinue the
medication, it should be tapered off over an eight-week or more
period. The patient’s medication should be gradually reduced and side
effects monitored during this time period.
SUMMARY
The patient is an extremely resilient person who has had a "horrifying" experience
associated with his job. He has been unsuccessful in coping with the upset associated with
his trauma.
Traumatized persons will often initially present their emotional distress through
insomnia, minimizing or denying traumatic events.
Traumatized persons can "self-medicate" using alcohol, drugs, and medications.
They also can engage in other high-risk health behaviors, including cigarette
smoking and unsafe sex.
The trauma story is usually present in the nightmares.
A grief reaction may mask more serious illnesses such as depression and PTSD.
These two diagnoses are often comorbid.
SSRIs are the treatment of choice for depression and PTSD.
The nightmare symptom is often difficult to treat and requires a second drug such as
trazodone. In many cases in primary care, failure of psychiatric medications is not due inefficacy
of the drug, but often to other factors such as poor compliance on the part of the
patient, too low dose, too high dose leading to side effects, or the patient’s inability
to obtain the medication due to financial troubles. If the PCP has addressed all of
these issues and the medication is still ineffective, the PCP should then try a different
antidepressant. If trials of the new medication fail, then consider referring elsewhere
for a psychopharmacology consultation.
References
1. DeVane CL, Nemeroff CB. "Clinical focus: 2002 guide to psychotropic drug
interactions." Primary Psychiatry. 9 (2002): 28-57.
2. Feinstein A, Owen J, Blair N. A hazardous profession: War, journalists, and
psychopathology. American Journal of Psychiatry. 159 (2002): 1570-5.
3. Harvard Program in Refugee Trauma (HPRT): Harvard Trauma Questionnaire.
4. Harvard Program in Refugee Trauma (HPRT): Hopkins Symptom Checklist-25.
5. Schenck, CH, Mahowald MW, Sack RL. Assessment and management of
insomnia. Journal of the American Medical Association. 289 (2003): 2475-9.
6. Schatzberg AF, Cole JO, DeBattista C. Manual of clinical psychopharmacology. 4th
ed. Washington, D.C.: American Psychiatric Publishing, Inc., 2003.
7. Buysse, DJ (2008). Chronic Insomnia. American Journal of Psychiatry, 165(6): 678-
686.
8. Glovinsky, PB, Yang, CM, Dubrovsky B, Spielman AJ. (2008). Nonpharmacologic
strategies in the management of Insomnia: Rationale and Implementation. Sleep
Medicine Clinics, 3:189-204.
Introduction
A 45 year-old single male comes to see you for a routine yearly physical examination. He
has been your patient for over ten years. He is a distinguished journalist for a major
national newspaper. In fact, he is a well-known news reporter, having just returned from
reporting on the conflict in Afghanistan.
The patient’s only complaint is a problem with insomnia since returning to America four
weeks ago. He tells you that he is feeling fatigued because he isn’t sleeping well.
You perform a complete physical examination, which is normal. You know this patient well;
he has no previous history of medical, psychiatric, or surgical treatments.
Question 1 out of 10 Which of the following statements is NOT correct regarding the diagnosis of insomnia in
this patient?
a. You should ask the patient whether he has had trouble sleeping in the past
The authors disagree. This statement is correct.
The clinical approach varies for acute vs. chronic insomnia. The patient tells you that he
hasn’t had problems with insomnia in the past.
b. You should ask the patient about the pattern of sleep disturbance
The authors disagree. This statement is correct.
It is important to determine the pattern of sleep disruption: trouble falling asleep (long
sleep latency); trouble staying asleep (excessive or prolonged awakenings); or feeling
unrefreshed after sleep. The patient reports trouble falling asleep and frequent brief
awakenings. He does not feel restored after a night’s sleep.
c. You should ask him about what he has already tried, if anything, to help with sleep
The authors disagree. This statement is correct.
Most patients try a variety of measures to help with sleep before consulting a physician.
The patient tells you he initially took some lorazepam that he had on hand for jet lag in
the past but ran out a couple of weeks ago.
d. You should assume that his sleep disturbance is caused by jet lag
The answer is correct.
The timing of this patient’s sleep disturbance is not consistent with circadian
disturbance as the sole cause for his current sleep disturbance, one month after return
from Afghanistan. While jet lag undoubtedly contributed to sleep disturbance in the first
week after his return, his circadian rhythm should have adjusted after a week or so.
Other factors that may be contributing to current sleep disturbance should be sought.
e. You should ask about his activity and diet
The authors disagree. This statement is correct.
The timing and nature of activity and dietary intake have major impacts on sleep and
should always be determined in evaluating any sleep disorder. This patient tells you that
he had trouble sleeping immediately when he returned from Afghanistan, so he started
staying up late to watch late-night comedy shows after getting home from work around 9
pm. He usually eats a large meal, often with a glass of wine, around 10 pm. He drinks
coffee while working during the afternoon. He also has an erratic bedtime, retiring
anywhere between 10 p.m. and 3 a.m.
Question 2 out of 10
Based on the previous information, you decide that the patient has acute onset insomnia
related to initial circadian rhythm disruption, with continuing conditioned insomnia related to
poor sleep hygiene.
Which of the following statements are correct regarding the management of insomnia in this
patient? (Hint: There are 2 correct answers, all must be selected)
a. You should advise an over-the-counter sleep aid such as diphenhydramine
The authors disagree.
Although over-the counter antihistamines are widely used, their efficacy for treatment of
insomnia has not been established. Diphenhydramine has a relatively long half-life and
is often associated with morning sedation.
b. You should review sleep hygiene principles with the patient
The answer is correct.
Based on the history you have obtained, poor sleep hygiene is likely to be playing a role
in this patient’s insomnia.
c. You should renew his prescription for lorazepam and advise him about short-term
intermittent use for insomnia
The answer is correct.
This patient has successfully used lorazepam in the past for treatment of circadian
disturbance. Although improvement in sleep hygiene may be of most value, judicious use
of lorazepam over the course of a few weeks may be helpful in reducing sleep latency.
You advise the patient to limit use to 2 or 3 times weekly to avoid dependence. An
alternative medication with demonstrated effectiveness for short-term insomnia and
limited potential for dependence would be zolpidem.
d. You should recommend further evaluation by a sleep specialist
The authors disagree.
The primary care clinician can initiate evaluation and management of many sleep
disorders, including this one, in the primary care setting.
e. You should give the patient a prescription for zaleplon
The authors disagree.
Zaleplon is an ultra short-acting agent that acts as an agonist at the benzodiazepine
receptor component of the gamma-aminobutyric receptor complex. It is useful primarily
for patients who report prolonged nighttime awakenings.
Sleep Hygiene Practices
Sleep hygiene practices that should be changed in this patient include:
Avoiding alcohol close to bedtime. The patient should have no alcohol within 5 hours
of bedtime. Alcohol is a poor hypnotic agent and can increase nighttime awakenings.
Avoiding caffeine after lunch, including coffee, tea, soda, and chocolate. Caffeine can
cause shallow sleep and nighttime awakenings.
Avoiding a heavy meal at bedtime. Going to bed on an empty stomach should also
be avoided. A light snack may be beneficial.
Adhering to a regular sleep schedule. Bedtime and wake time should be consistent
for 7 days a week, even after a bad night.
Other important sleep hygiene practices include:
Sleeping only as much as needed to feel rested. The patient should stay in bed for
roughly the number of hours of sleep he is achieving per night, rather than staying in
bed trying to get a few extra minutes of sleep.
Limiting stimulating or anxiety-producing activities during the two hours before bed.
Activities such as work, housework, or working on the computer should also be
avoided during a nighttime awakening.
Getting regular exercise. Over time, regular exercise has a positive effect on sleep
quality.
Avoiding use of the bed for anything other than sleep or sexual activity. During an
awakening that lasts more than 20 minutes or so, the patient should get out of bed
and do something relaxing and distracting, such as reading.
Adjusting the environment in the bedroom to reduce noise and light.
Question 3 out of 10 Two months have passed since the patient first came to you with complaints of
insomnia. The insomnia, in fact, has worsened. The patient admits that he is consuming
increasing amounts of alcohol to help him fall asleep – but it is no longer working. You
are wondering if the patient is dealing with an upsetting situation he has not shared with
you.
Which of the following statements are true? (Hint: There are 2 correct answers, all must
be selected)
a. When patients have had an experience of extreme violence, they can become self-
medicating with alcohol and other substances of abuse to treat their insomnia.
The answer is correct.
When consumed at bedtime, alcohol has an initial stimulating effect upon non-
alcoholics, followed by a decrease in time to fall asleep. However, with continued and
increased consumption until bedtime, alcohol’s disruptive effects on sleep increase and
its sleep-promoting effects decrease (Vitello, 1997).
b. Patients who have experienced extreme violence can have bad dreams but usually do not
have nightmares of the traumatic events.
The authors disagree.
Nightmares are common; the nightmare often reveals the tragic events that have
occurred. The PCP can usually have the patient reveal their trauma story by discussing
the content of their nightmares.
c. You should directly ask the journalist if he had a terrible experience in Afghanistan.
The answer is correct.
Proceed to the next slide to see the patient's answer.
He shares with you his recent experience. While driving outside of Kabul, he and his
friend, a photojournalist, were trapped in a barrage of rocket fire. He stepped out of the
car to see what was going on. A rocket was fired into the car injuring his colleague as he
watched from a hillside. He tried to approach the car but was turned back by more
rocket fire. He could not get to aid his friend for over two hours. By then, the
photojournalist had bled to death. He tells you how guilty he feels.
Case Progression
You directly ask the journalist if he had a terrible experience in Afghanistan, and he shares
with you his recent experience. While driving outside of Kabul, he and his friend, a
photojournalist, were trapped in a barrage of rocket fire. He stepped out of the car to see
what was going on. A rocket was fired into the car injuring his colleague as he watched from
a hillside. He tried to approach the car but was turned back by more rocket fire. He could
not get to aid his friend for over two hours. By then, the photojournalist had bled to death.
He tells you how guilty he feels.
He also tells you that he has been having almost nightly nightmares of a terrorist attack
blowing up a car that he is driving with his photojournalist colleague sitting beside him.
Question 4 out of 10 Upon hearing this story, you should diagnose the patient with PTSD.
a. True
The authors disagree.
b. False
The answer is correct.
The patient may fulfill the criteria for a DSM-IV diagnosis of PTSD. However, it must
first be considered that the patient has an acute grief reaction due to the tragic loss of
his friend. The patient’s initial presentation of insomnia is consistent with this diagnosis.
This patient also presented with some symptoms characteristic of a major depressive
episode, such as feelings of sadness associated with poor sleep, poor appetite, and
weight loss.
Screening Instruments
You are concerned that the patient is developing a major psychiatric disorder. You are on
the alert for this possibility during the patient’s next visit four (4) weeks later. On your
advice, he has stopped drinking, but the medication you have given him to help his sleep is
not working. He is feeling more despondent and guilty about his friend’s death. You decide
to administer to him a screening instrument for PTSD called the Harvard Trauma
Questionnaire (HTQ) and a screening instrument for major depression called the Hopkins
Symptom Checklist-25 (HSCL-25).
The scales reveal the following symptoms:
Table 01: Hopkins Symptom Checklist-25 (HSCL-25) - Depression Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Low energy . . X .
Self-blame . . . X
Crying X . . .
Lowered libido . X . .
Poor appetite . . X .
Difficulty sleeping . . . X
Hopelessness . X . .
Sadness . . . X
Loneliness X . . .
Suicidal ideation X . . .
Feeling trapped . X . .
Worrying . . X .
No interest . . X .
Everything an effort . . X .
Worthlessness . . X .
TOTAL SCORE = 39/15 = 2.60
(Depression score is determined by adding individual scores [1-4] for each item and dividing by
15; patient is "checklist positive" for major depression if score is >1.75)
Table 02: Harvard Trauma Questionnaire (HTQ) - PTSD Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Recurrent memories . . X .
Reexperiencing the event . . X .
Nightmares . . . X
Detachment X . . .
Unemotional X . . .
Startled X . . .
Poor concentration . . X .
Trouble sleeping . . . X
Guardedness X . . .
Irritability . X . .
Avoiding activities reminiscent of trauma X . . .
Inability to remember trauma .X . . .
Less interest in daily activities .X .X . .
Feeling there is no future X .X . .
Avoiding traumatic thoughts X .. .. ..
Sudden emotional or physical reaction
when reminded of trauma . X . .
TOTAL = 31/16 = 1.94
(PTSD score is determined by adding individual scores [1-4] for each item and dividing by 16;
patient is "checklist positive" for PTSD if score is >2.00)
Question 5 out of 10 Which of the following statements is true?
a. Based upon the two screening instruments, this patient is checklist positive for major
depression and PTSD.
The authors disagree.
The patient meets the threshold for major depression but not for PTSD.
b. The patient’s major PTSD symptoms are avoidance symptoms.
The authors disagree.
While the patient does not meet all DSM-IV criteria for PTSD, this patient reveals
serious PTSD symptoms of recurrent memory phenomena. That is, he is constantly
playing over in his mind memories of the death of his friend and colleague.
c. The patient has serious daily nightmares that disrupt his sleep. This PTSD symptom will
be relatively easy to treat with medication.
The authors disagree.
Nightmares are extremely difficult to treat with medication as already demonstrated by
the failure of standard use of benzodiazepines to treat his insomnia.
d. The patient diagnosed with major depression and partial symptoms of PTSD should be
initially prescribed an antidepressant. One good choice for major depression with PTSD
symptoms and/or PTSD is sertraline (Zoloft) or paroxetine (Paxil).
The answer is correct.
These selective serotonin reuptake inhibitors (SSRIs) are excellent first choices because
they are generally well tolerated and have a fairly quick onset of action.
Choices among SSRIs for major depression alone are fluoxetine (Prozac) and
escitalopram (Lexapro).
Question 6 out of 10 The patient should be told of the most common side effects of the SSRIs.
Which of the following are NOT common side effects of the SSRIs? (Hint: there are 2
correct answers, all must be selected)
a. Gastrointestinal problems such as nausea, vomiting, and diarrhea
The authors disagree.
b. Dizziness and drowsiness
The authors disagree.
c. Headaches
The authors disagree.
d. Dry mouth, weight gain, and vivid dreams
The authors disagree.
e. Sexual problems, including decreased libido, anorgasmia, impotence, and delayed
ejaculation
The authors disagree.
f. Serotonin syndrome
The answer is correct.
Although it may emerge in rare cases, serotonin syndrome is not considered a common
side effect of SSRIs.
g. Fatality with overdose
The answer is correct.
SSRIs do not cause fatalities upon overdose in suicidal patients.
Question 7 out of 10 In your pharmacological management of this patient you will:
a. "Start Low, Go Slow"
The answer is correct.
With any age it is recommended to maximize patient’s compliant use of the
antidepressant medication to start with as low doses as possible and then increase the
dosage slowly. This minimizes side effects and maximizes your potential for achieving a
therapeutic dose level.
b. Increase the dose of the SSRI in four week intervals
The authors disagree.
SSRIs should be increased in 1-2 week intervals. Most SSRIs take 2-3 weeks for initial
symptom reduction and require 4-6 weeks to reach full effectiveness once they reach
therapeutic dose range.
c. Treat the patient's depression with medication for six months once remission occurs
The authors disagree.
It is recommended that the patient’s symptoms be in remission for one year before
discontinuation of treatment.
Question 8 out of 10 This patient’s nightmares have not responded well to the initial SSRI.
You should add low dose trazodone to treat this symptom.
a. True
The answer is correct.
Nightmares in individuals who have experienced extreme violence are often poorly
responsive to antidepressants. The biology of this phenomenon is not known.
Empirically, low dose trazodone has been effective in treating nightmares.
b. False
The authors disagree.
Question 9 out of 10 After twelve weeks, you repeated the HSCL-25 and the HTQ. If symptom scores on the
HSCL-25 were over 1.75, you would not be too concerned since you would not expect
remission at this time.
a. True
The authors disagree.
b. False
The answer is correct.
After twelve (12) weeks, the symptom score on the HSCL-25 should be under 1.75,
indicating successful treatment of the patient’s depression. However, some patients may
show improvement in symptom severity while scoring greater than 1.75 on the HSCL-25.
In these cases of partial remission, the PCP should continue the medication by raising
the dose, if necessary, as well as reviewing other possible contributing factors, including
poor compliance and life events. Some patients who are severely psychologically
damaged from trauma may have chronic depressions that are difficult to treat, requiring
extra attention in getting proper levels of counseling and social support.
Partial remission of depression is a predictor of chronicity and re-exacerbation of
depressive illness.
Reduction in PTSD symptoms is usually tied to reduction in depressive symptoms.
Question 10 out of 10 After successful treatment, you and the patient decide to discontinue medication.
Which of the following statements is true?
a. You can taper off the medication over a two-week period.
The authors disagree.
Once the decision is made with the patient to discontinue the medication, it should be
tapered off over an eight-week or more period. The patient’s medication should be
gradually reduced and side effects monitored during this time period.
b. After eight weeks off medication the patient should be reevaluated for reoccurrence of
symptoms.
The answer is correct.
The patient should be seen again in eight weeks after medication has been discontinued
to monitor for relapse.
Summary
The patient is an extremely resilient person who has had a "horrifying" experience
associated with his job. He has been unsuccessful in coping with the upset associated with
his trauma.
Traumatized persons will often initially present their emotional distress through
insomnia, minimizing or denying traumatic events.
Traumatized persons can "self-medicate" using alcohol, drugs, and medications.
They also can engage in other high-risk health behaviors, including cigarette
smoking and unsafe sex.
The trauma story is usually present in the nightmares.
A grief reaction may mask more serious illnesses such as depression and PTSD.
These two diagnoses are often comorbid.
SSRIs are the treatment of choice for depression and PTSD.
The nightmare symptom is often difficult to treat and requires a second drug such as
trazodone.
In many cases in primary care, failure of psychiatric medications is not due inefficacy of the drug, but
often to other factors such as poor compliance on the part of the patient, too low dose, too high dose
leading to side effects, or the patient’s inability to obtain the medication due to financial troubles. If the
PCP has addressed all of these issues and the medication is still ineffective, the PCP should then try a
different antidepressant. If trials of the new medication fail, then consider referring elsewhere for a
psychopharmacology consultation.
References
1. DeVane CL, Nemeroff CB. "Clinical focus: 2002 guide to psychotropic drug interactions." Primary
Psychiatry. 9 (2002): 28-57.
2. Feinstein A, Owen J, Blair N. A hazardous profession: War, journalists, and psychopathology. American
Journal of Psychiatry. 159 (2002): 1570-5.
3. Harvard Program in Refugee Trauma (HPRT): Harvard Trauma Questionnaire.
4. Harvard Program in Refugee Trauma (HPRT): Hopkins Symptom Checklist-25.
5. Schenck, CH, Mahowald MW, Sack RL. Assessment and management of insomnia. Journal of the
American Medical Association. 289 (2003): 2475-9.
6. Schatzberg AF, Cole JO, DeBattista C. Manual of clinical psychopharmacology. 4th ed. Washington,
D.C.: American Psychiatric Publishing, Inc., 2003.
7. Buysse, DJ (2008). Chronic Insomnia. American Journal of Psychiatry, 165(6): 678-686.
8. Glovinsky, PB, Yang, CM, Dubrovsky B, Spielman AJ. (2008). Nonpharmacologic strategies in the
management of Insomnia: Rationale and Implementation. Sleep Medicine Clinics, 3:189-204.
Mental Health Sequelae of Extreme Violence Case 4: An Anniversary Reaction
Introduction
The patient is a 70 year-old Vietnamese man who has been your primary care patient for
the five years since he arrived in America. Your initial medical work-up and subsequent bi-
yearly primary care visits reveal a healthy elderly male with no medical problems except for
chronic obstructive lung disease. He was a 3-pack-a-day cigarette smoker since 15 years of
age. He uses an inhaler bronchodilator when he has difficulty breathing. Currently, he has
weaned himself down to ½ pack per day.
The patient is brought to your office today by the police for taking a Mercedes Benz parked
in front of a hotel and driving it into another state before being caught for speeding. The
police have brought him to you because he told them when he was stopped that the Viet
Cong were entering Saigon and he was escaping the city. He appeared to the police to be in
a state of panic and was serious about the current danger he was escaping.
You conduct a physical examination of the patient, and it is within normal limits.
You conduct a brief mental status examination and find that the patient can only remember
that it was April 30th, the anniversary of the fall of Saigon. He was feeling very upset when
he thought about his experiences during the Vietnam War. And then the next thing he
remembered was being in a police car in another state.
Question 1 out of 5 Which of the following are possible psychiatric symptoms associated with the event?(Hint:
There are 2 correct answers, all must be selected)
a. Anxiety
The authors disagree.
Memory loss associated with sudden unexpected travel from home is not associated with
anxiety.
b. Neurovegetative symptoms
The authors disagree.
Sleep, poor appetite, and other neurovegetative symptoms are not directly related to the
patient’s principal problem.
c. Impairment in level of consciousness
The authors disagree.
Patient revealed no signs of impairment in level of consciousness, disorientation, or
delirium.
d. Depersonalization
The answer is correct
The patient has revealed signs of depersonalization, which is characterized by a feeling
of detachment or estrangement from oneself (i.e., feeling like one is in a dream).
e. Dissociation
The answer is correct
This patient is suffering from having experienced a dissociative state. That is, a state in
which a coordinated set of activities, thoughts, attitudes or emotions become separated
from the rest of the person’s personality and functions independently. Two major
characteristics of dissociation are: (1) a disturbance in the individual sense of identity,
and (2) a disturbance in memory.
Further Questioning of the Patient
Further questioning of this patient reveals that he meets all of the DSM-IV criteria of a
dissociative fugue state. These criteria include:
A. The major disturbance is sudden, unexpected travel away from home or one’s customary
place of work, with the inability to recall one’s past.
B. Confusion about personal identity or assumption of new identity (partial or complete).
C. Disturbance is not due to dissociative identity disorder (formerly Multiple Personality
Disorder) or the direct physical effects of drugs or a general medical condition.
D. Symptoms cause significant distress or impairment in functioning.
While this patient did not meet the full criteria since he was not confused about his identity
in the doctor’s office, he did reveal major identity confusion with the police while he was
being arrested.
Question 2 out of 5 In order to make the diagnosis of dissociative fugue state, which of the following do you
have to rule out as the potential causes of his current episode?
a. Head injury
Correct, but there are more choices to consider.
The patient’s dissociative symptoms and memory loss could be the result of head injury.
b. Complex partial seizures
Correct, but there are more choices to consider.
Individuals with complex partial seizures can exhibit wandering or semi-purposeful
behavior during seizures or a postictal state. However, an epileptic fugue can usually be
identified by: aura, motor abnormalities, stereotyped behavior, perceptual alterations,
postictal state, and abnormal EEG.
c. Substance abuse
Correct, but there are more choices to consider.
Dissociative states can be caused by drug abuse, alcohol, and medication.
d. Psychosis or manic episode
Correct, but there are more choices to consider.
Psychotic behavior and manic episodes can lead to abrupt disorganized travel. Other
primary symptoms associated with the behavior can be found such as disorganized
thinking and speech, hallucinations, delusions, or grandiosity and other signs of
hypermania. The patient would not have a clear sensorium in the doctor’s office except
for the poor memory of the event.
e. Malingering and/or criminal behavior
Correct, but there are more choices to consider.
Malingering, or the faking of fugue, may occur in individuals with serious legal, social,
or personal problems, or in individuals such as soldiers trying to escape dangerous
assignments. An attempt may also be made to hide an intentional criminal act.
Although this patient "stole" a car, there is no prior history that he has ever been
involved in prior criminal behavior or had anything to gain from flagrantly driving off in
a Mercedes Benz with no apparent destination in mind.
f. All of the above
The answer is correct
The patient’s current situation makes you aware that he might have been seriously
traumatized during the Vietnam War. In over five years of treatment as your patient, he has
never discussed his prior military history with you. During your next visit, you find out that
he was captured by the Viet Cong and violently tortured during the war. On April 30, 1975,
during the fall of Saigon, he was unable to escape with his American GI friends.
Subsequently, he was captured by the communists and put in a brutal reeducation camp for
ten years. Only five years ago was he able to resettle in America with his relatives. He never
married or had children. He lives with his sister’s family in America.
Question 3 out of 5 You now believe this patient’s dissociative fugue state was secondary to an "anniversary
reaction," since it occurred on the same day as the fall of Saigon. This makes you think the
patient may have the following associated psychiatric problems: (Hint: There are 3 correct
answers, all must be selected)
a.
Posttraumatic stress disorder (PTSD)
The answer is correct.
This is a patient with an extensive trauma history, including a history of torture and
brutal incarceration. Dissociative symptoms are often a feature of PTSD.
You administer the Harvard Trauma Questionnaire. It reveals the following:
Table 01: Harvard Trauma Questionnaire (HTQ) - PTSD Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Recurrent memories . . X .
Reexperiencing the event . . . X
Nightmares . . X .
Detachment . . X .
Unemotional . X . .
Startled X X . .
Poor concentration . . X .
Trouble sleeping . . X .
Guardedness . X . .
Irritability . X . .
Avoiding activities reminiscent of trauma . . X .
Inability to remember trauma .X . . .
Less interest in daily activities X .. . .
Feeling there is no future . X . .
Avoiding traumatic thoughts . .. X ..
Sudden emotional or physical reaction
when reminded of trauma . . . X
TOTAL = 2.56 (Checklist positive for PTSD if >2.00)
b.
Major depression
The answer is correct.
Major depression is often comorbid with PTSD. You administer the Hopkins Symptom
Checklist-25 and it reveals the following:
Table 02: Hopkins Symptom Checklist-25 (HSCL-25) – Depression Symptoms Only
Symptoms (1)
Not At All (2)
A Little (3)
Quite A Bit (4)
Extremely
Low energy . X . .
Self-blame . . . X
Crying X . . .
Lowered libido X . . .
Poor appetite . . X .
Difficulty sleeping X . X .
Hopelessness X . . .
Sadness . . X .
Loneliness . X . .
Suicidal ideation X . . .
Feeling trapped . . X .
Worrying . . . X
No interest X .. . .
Everything an effort X . . .
Worthlessness . .. . X
TOTAL SCORE = 2.27 (Checklist positive for major depression if >1.75)
c.
Substance abuse
The answer is correct.
Although this patient has never abused drugs and/or alcohol, you now have a very good
understanding of his 3-pack-a-day cigarette habit. You will now be able to have a
different approach to weaning him off his remaining ½ pack by treating his PTSD and
depression first.
Improvement and prevention of further lung problems could then proceed more
effectively.
d.
Somatization disorder
The authors disagree.
Although dissociative symptoms can occur in somatization disorder, this patient does not
somatize his traumatic life history and emotional distress. His lung disease is real. He
does not have a pattern of recurring, multiple, clinically significant somatic complaints
without an adequate medical explanation.
In fact, this patient is extremely stoic and has not shared his traumatic history with the
doctor until the recent anniversary reaction.
e.
A culturally defined “running diagnosis” or folk diagnosis
The authors disagree.
There is no known "running syndrome" in Vietnamese culture such as pibloktog in native
peoples of the Arctic or amok in Indonesia. This patient also did not believe he was
possessed by a demon or was affected by a limited and well-circumscribed trance (that is,
dissociative trance disorder).
Question 4 out of 5 You decide to start the patient on a psychotropic drug. Which of the following do you select?
a. Mood stabilizers such as lithium
The authors disagree.
This patient is not revealing signs of a "hypomanic" state.
b. Benzodiazepine
The authors disagree.
This class of drugs will not affect the patient’s primary diagnosis of PTSD and major
depression.
There is no evidence that they will prevent the patient from developing a new
dissociative state in the future or prevent a new anniversary reaction next year.
c. Anticonvulsants
The authors disagree.
This class of drugs will not treat the patient’s primary psychiatric diagnosis or prevent a
future dissociative state.
d. Tricyclic antidepressants
The authors disagree.
While these drugs are effective for treating PTSD and depression, they have many side
effects, especially in Asian patients.
e. SSRIs, including sertraline (Zoloft) or paroxetine (Paxil)
The answer is correct.
Zoloft and Paxil are recommended for depression comorbid with PTSD.
Question 5 out of 5 Although you started the patient on a low dose of antidepressants, and have advanced the
dose slowly, you notice that the patient is responding poorly with little symptom reduction
after twelve weeks on the medication. You have brought the patient up to the full
recommended therapeutic dose weeks ago.
In assessing the current potential of the medication, which of the following should you
consider?
a. Asians respond to the same dose of antidepressants as Caucasians. Maybe the patient
needs a higher dose.
The authors disagree.
Asians usually respond to lower doses of antidepressants, requiring starting doses and
maintenance doses at half of that recommended for Caucasians.
b. Patient is having uncomfortable side effects.
The authors disagree.
The drug dose must be titrated against side effects since there is no biological marker
indicating when threshold has been reached. Asian patients easily develop side effects at
relatively low doses.
c. Patient has cultural beliefs against the use of medication.
The answer is correct.
Patients may believe the drug is "addicting" or that it does not have to be taken
everyday.
d. Patient has a conflict between the use of traditional healing and psychotropic drugs.
The authors disagree.
Although Southeast Asian patients often engage in traditional healing, they usually do
not see a conflict with Western medicine. In order to recover, they will use both
approaches simultaneously.
e. Patient prefers counseling to medication.
The authors disagree.
Southeast Asian patients prefer medication to counseling. In this case, the doctor will
have to extend himself to the patient by teaching the patient the cause of the fugue state
and the patient’s current psychiatric diagnosis. The doctor should also offer to listen to
an account of the patient’s trauma history – to be told when the patient is ready to reveal
his painful life experiences.
Summary
Health and mental health practitioners should be alerted to the fact that any Southeast
Asian immigrant may have a serious trauma history. This elderly gentleman was sitting on a
"time bomb" from previous torture and incarceration that exploded during an anniversary
reaction – the April 30, 1975 fall of Saigon.
In suspected cases of trauma, always gently inquire about the patient’s trauma
history
Be able to recognize the trauma-related symptoms of dissociation and
depersonalization
Identify and diagnose dissociative fugue states
Identify and diagnose comorbid diagnoses of posttraumatic stress disorder and major
depression
Administer and monitor antidepressants with attention being paid to patients’:
Ethnic and cultural background
Fear of medication
Sharing with friends and relatives
Lower metabolism leading to side effects at lower doses
Lower therapeutic dose range than for Caucasians
Simultaneous use of traditional healing, including herbal medications
In many cases in primary care, failure of psychiatric medications is not due inefficacy of the
drug, but often to other factors such as poor compliance on the part of the patient, too low
dose, too high dose leading to side effects, or the patient’s inability to obtain the medication
due to financial troubles. If the PCP has addressed all of these issues and the medication is
still ineffective, the PCP should then try a different antidepressant. If trials of the new
medication fail, then consider referring elsewhere for a psychopharmacology consultation.
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 4th ed. Washington, DC: Author, 1994.
2. Foa EB, Hearst-Ikeda D. "Emotional dissociation in response to trauma." In Handbook of
Dissociation. Michelson LK, Ray WJ, eds. New York: Plenum Press, 1996; 207-224.
3. Harvard Program in Refugee Trauma (HPRT): Mental Health Screening.
4. McPhee SJ. Caring for a 70-year-old Vietnamese woman. Journal of the American Medical
Association. 287 (2002): 495-503.
5. Ruiz P, ed. Ethnicity and psychopharmacology. Washington, DC: American Psychiatric
Press, 2001.
6. Mollica RF, Lyoo IK, Yoon SJ, Culhane MA, Kim JE, Villafuerte RA, Diamond D. Brain
Structural Abnormalities in South Vietnamese Ex-Political Detainees Who Survived Torture:
Linking Traumatic Head Injury to Mental Health Sequelae Decades Later. Archives of
General Psychiatry. Nov 2009; 66(11): 1221-1232.
Mental Health Sequelae of Extreme Violence Case 5: Birds on Fire
Introduction
A 45 year-old businessman is looking out of his Empire State Building office window onto
the World Trade Center twin towers. He is shocked by witnessing a plane fly into one of the
towers, followed by another plane that hits the other building. The whole scene seems to
him unreal, that science fiction has become reality. As he stares dumbfounded onto this
scene he sees what looks like little birds on fire falling out of the towers toward the ground.
In a moment of horror, he realizes he is seeing people on fire jumping out of the buildings.
A week passes and he is unable to get those images of the falling "birds on fire" out of his
mind. He is having trouble sleeping and bad dreams of the planes hitting the buildings. He is
increasingly afraid to take the New Jersey train to work, especially after he realizes that
many of his fellow passengers on this train were killed in the World Trade Center attacks.
He finds the train, which always had standing room only, is now half empty of passengers.
This creates in him an eerie and strange feeling.
His wife, on noticing his upset, recommends he consult with his primary care physician.
The patient arrives in your office with the above description, primarily complaining of
recurrent nightmares and flashbacks of "birds on fire." He cannot sleep, is tired all day long,
and is afraid to go to work. When at work, he cannot concentrate and is unable to function
in his usual highly efficient capacity.
He asks the doctor for help.
Question 1 out of 4 Which of the following should you consider the possible diagnoses for your patient after
obtaining an extensive history of the recent trauma he has experienced related to the
September 11, 2001 terrorist attacks?
a. Generalized anxiety disorder
The authors disagree.
This patient has no history of chronic anxiety or panic attacks. The essential feature of
generalized anxiety disorder is excessive anxiety or worrying, occurring on most days
for at least six months. The patient’s symptoms have only existed for one week.
b. Substance abuse
The authors disagree.
Could be a factor if patient was abusing drugs and/or alcohol as a way of self-
medicating his symptoms. He was not using alcohol or drugs.
c. Mental disorder due to general medical condition
The authors disagree.
He has no medical problems that could be causing these symptoms, such as head injury
from a car accident.
d. Psychosis
The authors disagree.
The patient is clear and articulate and is revealing no signs of a psychosis. His
symptoms are based upon real facts and are not due to hallucinations or delusions.
e. Acute stress disorder
The answer is correct.
This is the most likely diagnosis. Symptoms of acute stress disorder are experienced
during or immediately following a severe trauma, last at least two days, and resolve
within four weeks. After four weeks it becomes PTSD.
Acute Stress Disorder
This previously healthy and highly functioning businessman meets the trauma criteria for an
acute stress disorder. He has witnessed a serious terrorist attack, including seeing human
beings jumping out of a burning building to their death. This experience has filled him with
feelings of fear, hopelessness, and horror.
You find that he meets the full criteria for acute stress disorder:
A. Dissociative symptoms
To meet these criteria, the patient needs to have three (3) or more of the following
dissociative symptoms:
(1) Numbness, detachment, or absence of an emotional response
(2) Reduction in awareness of surroundings, "being in a daze"
(3) Derealization; that is, an alteration in the perception of the environment with the sense
that somehow one has lost contact with external reality. A common component of:
(4) Depersonalization; that is, an emotional disorder in which there is a loss of contact with
one’s own personal reality, a derealization accompanied by feelings of strangeness and an
unreality of experience. Depersonalization involves an alteration in the perception of the self
so that the individual’s sense of reality is lost or altered. This may include feelings of
estrangement or unreality. There may be alterations in body perceptions, such as the sense
of becoming very large or small, or the feelings that one’s body parts do not belong to one;
or the feelings that one’s body parts have changed in size. The individual may have out-of-
body experiences in which the person views himself or herself as if from a distance or from
above. The person may report feeling "dead," "mechanical," or as if "in a dream.
(5) Dissociative amnesia, inability to recall an important aspect of the trauma
The patient has (1), (2), (3), and (4).
B. Recurrent memory phenomena
This patient has a persistent problem with flashbacks, nightmares, memories, and bad
dreams of the event.
C. Avoidance of thoughts, places, and people that remind him of the trauma.
He wants to avoid at all costs riding the train and going into Manhattan.
D. Marked symptoms of anxiety and arousal (e.g., poor sleeping, irritability, poor
concentration, hypervigilance, exaggerated startle response, motor restlessness).
The patient has all of these symptoms except we do not know if he has an exaggerated
startle response and motor restlessness. You check the latter and he has these symptoms
as well.
E. Significant distress leading to impairment in social and/or occupational activities.
Patient is a highly successful man who is unable to function effectively at work.
Question 2 out of 4 You have made the diagnosis of acute stress disorder secondary to the 9/11 terrorist
attacks.
In your management of the patient, you should consider:(Hint: There are 2 correct answers,
all must be selected)
a. Immediately prescribing a medication for his insomnia and nightmares.
The authors disagree.
This patient may not need medication for these symptoms. Benzodiazepines may be used
temporarily for his acute sleep problems, but you should be concerned about
habituation.
b. Medication for PTSD and/or depression.
The authors disagree.
The patient may go on to develop PTSD and/or depression. However, in 80% of patients
with acute stress disorder, more serious mental health problems do not develop.
c. Debriefing
The authors disagree.
Considerable evidence now exists that critical incident stress debriefing (where you
review the trauma in detail) either has no beneficial effect or can exacerbate the
development of PTSD.
It is believed that debriefing is potentially toxic because it 1) generates high emotional
upset; 2) unduly worries the patient about possible PTSD development; and 3) is too
brief to help the patient deal with the emotions generated by the trauma.
d. Listening intently to the patient’s trauma story
The answer is correct.
Provide opportunity for the patient to tell their trauma story at their own pace. The
traumatic story can be optimally shared in small vignettes over a number of meetings
with the patient.
e. Supportive counseling
The answer is correct.
The doctor-patient relationship is the most important therapeutic tool. The health care
practitioner, whether it is a doctor, nurse, or mental health practitioner, can reassure
the patient with a "good" diagnosis that they will completely recover and that their
symptoms are a "normal" response to an "abnormal" situation.
Question 3 out of 4 The patient now feels reassured by your preliminary diagnosis. The patient asks you what
can be done to help relieve his distress.
Which of the following should you not recommend to the patient?
a. Keep up the coping strategies that have been helpful already
The authors disagree.
Most individuals will seek support from relatives, friends, and their clergy. You should
encourage this.
b. If necessary, take a short holiday, but return to work as soon as possible.
The authors disagree.
Trauma victims recover faster if they keep working; in fact, work enhances resiliency
against depression and PTSD. Individuals can try to reduce emotional upset by taking a
short break if necessary, but should ultimately return to work.
In this particular instance, however, because the patient experienced the trauma while in
his office, the emotional triggers in his work environment may actually become toxic
enough that he will have to switch jobs. This possibility should be considered and
monitored.
c. Engage in spiritual and altruistic activities
The authors disagree.
The effects of terrorism are associated with larger existential questions of social justice,
evil, and mortality. Individuals can seek help from religious institutions, clergy,
spiritual, political, or humanistic beliefs, systems, and organizations. Altruistic activities
can also be very therapeutic.
d. Find a place to ventilate the emotions associated with the trauma
The answer is correct.
The patient may need a safe and secure environment to discuss his upset. It has not been
proven that an undisciplined ventilation of emotional upset is therapeutic; it has also not
been demonstrated that complete denial of the trauma and associated affect is beneficial.
A middle pathway is most likely best, where you acknowledge the trauma and its
emotional consequences but you help the patient gain control of intrusive memories,
nightmares, and feelings of fear and dread. The patient can be taught how to recognize
and bring their emotions under control whenever they come to a "boil." At times a
benzodiazepine can help facilitate this process on a temporary basis.
e. Warn against the possibility of participating in high-risk behaviors such as smoking,
drug and alcohol abuse, and unsafe sex.
The authors disagree.
Patients with acute stress disorder are at increased risk for engaging in negative health
behaviors. Educate the patient to this fact.
Question 4 out of 4 You have treated many patients such as this one in the past few weeks following the
terrorist attacks. Not surprisingly, many of your relatives had similar types of experiences,
although none have died. The anthrax scare has also made you feel afraid of the risk of
being a front-line medical worker, if another attack occurred.
Which of the following are appropriate reactions to your own emotional distress? (Hint:
There are 3 correct answers, all must be selected)
a. Keep it to yourself because it might upset your family and colleagues.
The authors disagree.
You have to have some way of realistically assessing your personal danger or health
risks, including ongoing emotional distress.
b. Be concerned about developing acute stress disorder yourself
The answer is correct.
Clinicians working with survivors of extreme violence should look out for symptoms of
acute stress disorder in themselves because
1) they or their family members may have also been directly traumatized by the event,
2) they may feel endangered by the work
they are doing itself (i.e., as first-line responders to violence), and
3) they can absorb some of the pain and suffering of the people they're serving, so it's
not uncommon to develop nightmares and/or other sleep disturbances similar to
their patients'.
c. Attend to the needs of your patients first; your family and yourself come second.
The authors disagree.
Health professionals tend to have a "macho" attitude. However, they cannot be
maximally effective if they do not attend to the safety and security of themselves and
their family members. Responses to terrorism are unique, since health practitioners and
patients share similar risks and dangers from perpetrators and extreme violence.
Unfortunately, in some situations, doctors, nurses, hospitals, clinics, and patients are
actually targets of violence.
d. Use relaxation and other stress reduction techniques; be on the lookout for increase use
of alcohol, drugs, and/or medications.
The answer is correct.
Engage in stress reducing techniques; monitor and avoid "self-medicating" oneself.
e. Discuss stress and problems with colleagues on an ongoing basis.
The answer is correct.
Professional non-therapy support groups modeled after Balint groups enhance problem
solving and reduce stress among health care workers.
Summary
After a terrorist attack, traumatized persons primarily seek help from their indigenous
healing community. The indigenous healers in America and abroad include friends, family
and relatives, the clergy, traditional healers, and primary care practitioners.
Health and mental health care professionals are in an ideal position to help their patients
"cope" with the emotional distress and lack of control associated with mass violence. Simple
but effective interventions can increase resiliency as well as prevent the development of
serious psychiatric illnesses.
In patients that have suffered from a terrorist attack or other forms of mass violence, always ask
the question: "Many of my patients have felt that experiences of trauma, torture, or terrorism
(e.g., the September 11th attacks) have had a big effect on their health and well-being. Has this
been the case for you?"
Be able to identify acute stress disorder in culturally diverse populations
Provide effective interventions that include:
Acknowledging and supporting the patient’s own coping mechanisms
Recommending 1) work; 2) altruistic behavior; 3) spiritual involvement and practices
Continuing to help patient deal concretely with realistic fear (e.g., security, loss of home) and to
reduce high levels of emotional distress and disturbing memories.
Provide an optimistic and valid prognosis that their reactions are "normal" responses to
abnormal events, and that 80% of all affected individuals recover completely
Set up follow-up sessions and provide ongoing monitoring and support
Reduce health care provider distress by using relaxation techniques and discussing upset/fears
with other colleagues
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th
ed. Washington, DC: Author, 1994.
2. Foa EB, Meadows EA. Psychosocial treatments for posttraumatic stress disorder: A critical
review. Annual Review of Psychology. 48 (1997): 449-80.
3. Harvard Program in Refugee Trauma (HPRT): Terrorism Recovery Impact
4. Koopman C, Classen C, Spiegel D, Cardena E. When disaster strikes, acute stress disorders may
follow. Journal of Traumatic Stress. 8.1 (1995): 29-46.
5. Mollica RF. Assessment of trauma in primary care. Journal of the American Medical
Association. 285 (2001); 1213.
Mental Health Sequelae of Extreme Violence: Overview and Summary:
Introduction
Mass violence has a widespread impact on society
The primary care environment is an opportunity to detect and help those in need
This is a global health issue
What You Can Do
1. Ask about the patient’s "trauma story"
2. Identify concrete physical & mental effects
3. Diagnose & Treat generalized anxiety, depression, posttraumatic stress disorder/acute
stress disorder, complicated grief reaction & chronic insomnia
4. Refer screened cases of serious mental illness
5. Reinforce & Teach positive coping behaviors
6. Recommend altruism, work & spiritual activities
7. Reduce high-risk behaviors
8. Be Culturally Attuned in communicating & prescribing
9. Prescribe psychotropic drugs if necessary
10. Close & Schedule follow-up visits
11. Prevent Burnout by discussing with colleagues
1. ASK about the patient's trauma story
Ask the question! For example:
"Many of my patients have felt that experiences of trauma or torture have had a big
effect on their health and well-being. Has this been the case for you?"
Sometimes an experience of extreme violence will prompt the patient to reveal prior
traumatic experiences that he/she has been reluctant to share with the PCP.
Listen to the answer and acknowledge the patient’s trauma story; use words like "I
see," or "I can appreciate how that would bother you..."
2. IDENTIFY concrete physical or mental effects
By identifying the concrete physical and psychological effects of mass violence, the
PCP can help the patient note these effects and be reassured that their symptoms
are normal and usually temporary.
- Is the patient complaining of any physical symptoms such as headaches, stomach
upset, back pain, fatigue, or weakness?
- Is the patient exhibiting feelings of grief, anxiety, depression, or PTSD?
Patients with pre-existing psychiatric disorders that worsen following trauma related
to war or mass violence may need adjustment in medications and increased
psychosocial support
3. DIAGNOSE & TREAT most patients
After a human-rights related trauma, almost everyone will experience some transient
physical or psychological symptoms
- The majority will not suffer from serious mental illness and will benefit from your
counseling on the nature of their symptoms and coping techniques
- A small minority will develop a specific psychiatric disorder, including grief reaction,
generalized anxiety disorder, depression and/or PTSD, acute stress disorder, and
insomnia
Use HPRT’s screening instruments, available online at www.hprt-cambridge.org, to
help you decide if serious mental illness is present
4. REFER screened cases of serious mental illness
Many trauma-related mental health conditions will recede with the help of the PCP’s
reassurance and psychological support; some, however, will develop into true
psychiatric disorders.
Consider screening and referral to a mental health professional in the following
circumstances:
- Danger to self or others
- Complicated grief
- Severe forms of PTSD and/or depression
- Physical and social disability
5. REINFORCE/TEACH positive coping behaviors
You can help a patient by simply reinforcing positive behavior and teaching coping
techniques.
Patients usually hold their PCPs in very high regard. PCPs must take advantage of
this positive regard to validate whatever coping strategies are already being used.
- "Keep up the good work! It is good for you and will help you cope."
Recommend coping strategies beginning with self-care.
- Remind the patient to build physical, spiritual, AND mental strength
6. RECOMMEND altruism, work & spiritual activities
Scientific studies of survivors of mass violence have repeatedly revealed increased
resilience associated with altruism, work, and spiritual activities.
- Engaging in these activities and behaviors appears to prevent mental health
problems and promote recovery from existing problems
PCPs should actively recommend these activities
- "I strongly recommend that you work and keep busy, try to help others, and
consult with your clergy or engage in spiritual activities such as meditation or
prayer."
You have the power to recommend a positive change in behavior!
7. REDUCE high-risk behaviors
Patients often increase their use of cigarettes, drugs, and alcohol, or become
involved in risky sexual behavior during times of crisis. PCPs must be alert for these
unhealthy activities.
Inquire about high-risk behaviors:
- "Have you started to use or increase your use of cigarettes, drugs, or alcohol?"
and/or "Are you having unprotected sex?"
If the response is positive, recommend steps to reduce these high-risk activities
8. BE CULTURALLY ATTUNED to differences
Different cultures have different views of trauma and different ideas about the cause
of illness
- HPRT’s booklet of primary care provider resources describes the most common
symptoms of emotional distress for different cultural groups
Learn how to properly work with medical interpreters–choose someone with both
language and context skills
Culturally diverse patients have different reactions to doses and side effects
- Consider ethnically influenced factors like tolerance levels and body weight
(ethnopsychopharmacology is important!)
Be aware of a patient’s pre-existing "threshold" for trauma
9. PRESCRIBE psychotropic drugs if necessary
Prescribe medication where appropriate
Pay attention to dosage and side effects in culturally diverse populations
Use HPRT’s ethnopsychopharmacology pamphlet for simple, culturally appropriate
guides about drugs most commonly used to treat generalized anxiety disorder,
depression, PTSD, and insomnia
10. CLOSE & SCHEDULE follow-up visits
PCPs need a method for sensitively closing the interview, especially after a traumatic
history has been revealed
- "Thank you for telling me about these upsetting events. You have helped me
understand your situation better."
Ask the patient, "How would you like me to help you?" The answers of some patients
may be very specific; others may have no idea what help they may need.
It is important to create a relationship and continuous dialogue with the patient.
Make a plan with the patient that includes follow-up visits and further discussion of
the trauma story; just an additional conversation at a later date can do wonders for
a patient’s mental strength
Add the trauma story and diagnosis to the patient’s record
11. PREVENT BURNOUT: discuss with colleagues
Long-term involvement in the care of survivors of mass violence and torture may
lead to the state of chronic stress and fatigue known as "burnout" among PCPs
Acts of mass violence directly affect the practitioner as well as the patient
- As members of the community, PCPs may also suffer mental health consequences
of terrorism
You can prevent burnout by regularly discussing cases and your reactions with at
least one colleague–in the same way a patient benefits from talking to you, you will
gain strength from talking to others
Call to Action
This is a global, public health, medical, personal, and social justice issue of historic
magnitude
You are the indigenous healers
You can help people cope
You will maximize individual and social resiliency
Simple steps have a major impact
Customizing the 11 Points
The aforementioned 11 points should be customized for PCP settings that have
special patient populations or clinical needs.
Every PCP environment should modify these 11 points to maximize their cultural
sensitivity and clinical effectiveness
HPRT
Harvard Program in Refugee Trauma (HPRT)
Massachusetts General Hospital<
22 Putnam Avenue
Cambridge, Massachusetts 02139
HPRT’s Primary Care Provider (PCP) Toolkit: "Healing Wounds of Mass Violence"
contains the following items:
Comprehensive 11-Point Pamphlet: "Healing the Wounds of Mass Violence:
Refugees, Asylum Seekers, and Civilian Survivors of Mass Violence and Torture"
11-Point Reference Pocket Card: a concise, portable list of the 11 Points
Simple Screen for Depression/PTSD
Primary Care Provider Resources: 30 primary source essays by experts in the field
Article: "Prescribing Psychotropic Drugs Across Populations" by David C. Henderson,
MD
Article: "Pharmacological Treatment of Depression in Refugee Patients and Civilian
Survivors of Mass Violence" by Marguerita Reczycki, MEd, APRN, PC, Stephen
Luippold, APRN, and Giovanni Muscettola, MD
Manual: "Measuring Trauma, Measuring Torture: On the Use of the Harvard Program
in Refugee Trauma’s Versions of the Hopkins Symptom Checklist-25 (HSCL-25) and
the Harvard Trauma Questionnaire (HTQ)" by Richard F. Mollica, MD, MAR, Laura
McDonald, MALD, and Michael P. Massagli, PhD
CD-ROM with PowerPoint presentation: "Healing the Wounds of Mass Violence and
Torture in Primary Health Care"
To obtain a PCP Toolkit, or any of HPRT’s screening instruments (including the
Harvard Trauma Questionnaire and Hopkins Symptom Checklist-25), manuals, or
publications, please see www.hprt-cambridge.org or call (617) 876-7879.
Acknowledgements
Kathleen M. Rey, of the Harvard Program in Refugee Trauma (HPRT), was instrumental
in the creation, editing, formatting, and design of all course content.
HPRT acknowledges its colleagues at the Mellon Foundation for their support of HPRT’s
activities immediately following the tragic events of September 11, 2001. Funding from
Mellon initiated the creation of HPRT’s Primary Care Provider Toolkit for treating the wounds
of mass violence in primary care, which in turn formed the foundation of this CME course.
The objective of the Mellon Foundation is to "aid and promote such religious, charitable,
scientific, literary, and educational purposes as may be in the furtherance of the public
welfare or tend to promote the well-doing or well-being of mankind." For this vision, we
thank them.
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